How far should hospitals go to treat obese patients?

Boston Emergency Medical Services recently debuted an ambulance with a mini-crane and reinforced stretcher to transport patients weighing up to 850 pounds. It cost $12,000 to retrofit the ambulance.

My problem is this: I think we need to do our best to provide medical care to all patients. But patients need to take some basal level of responsibility for their own health. If you’re saying that you got to be 850 pounds due to a “glandular problem,” you’re blowing smoke.

Let’s say you want to go hiking in some secluded location or you want to go spelunking far beneath the surface of the earth. When you take those risks, you implicitly accept the chance that if something happens to you, there’s not going to be an acute care clinic at the 3,000 foot mark on the mountain you want to climb. If you get hurt, you aren’t going to have access to the medical care that might otherwise be available to you. You may take your cell phone with you and may make arrangements for air medical transport if needed, but even with those precautions, you just might die from your injuries based solely on the risks you took – and no one is to blame but you.

If alcoholic patients drink to the point that they develop liver failure and then they continue drinking alcohol, most hospitals will not perform liver transplants. You got yourself into that situation, you refuse to help yourself get out of that situation, the system isn’t going to invest massive amounts of resources into your care – and no one is to blame but you.

Should people who eat themselves to death be treated any differently?

Should it ever be right to tell patients that if they let themselves get so obese that traditional ambulances can’t carry them that dispatchers will tell refuse transport and they will be responsible for their own transportation to the hospital?

If we continue down the road that we must accommodate the medical needs of every morbidly obese patient, are we then going to require that all hospitals purchase CT scanners and MRI scanners to accommodate patients of all weights – if those scanners even exist? Will every hospital be required to maintain an additional set of beds, commodes, bathroom fixtures, blood pressure cuffs, and a plethora of other utilities solely to treat morbidly obese patients.

Or perhaps we create regional system of care for morbidly obese patients. One regional hospital gets all the necessary equipment to manage the medical needs of morbidly obese patients and any morbidly obese patient requiring testing or admission must be transported to one of these centers. Hospitals can transfer trauma patients if they don’t have a trauma surgeon, shouldn’t they also be able to transfer bariatric patients if they don’t have a bariatric specialist?

This post is not meant as an attack on morbidly obese people, but more intended as a reality check. What should be a rational method of dealing with morbidly obese patients? If we require EMS and hospitals to make all these expensive modifications for morbidly obese patients, where do the accommodations end for other patients with other medical conditions needing costly medical care?

And how long is it going to be before the lawyers file a claim against a hospital when a patient dies because the hospital didn’t have those modifications?

WhiteCoat is an emergency physician who blogs at WhiteCoat’s Call Room at Emergency Physicians Monthly.

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  • Diane D’Angelo

    So where does that end? Not treating people for heart problems if they smoke or eat bad food? What is called “tough love” is all too often an excuse to abdicate our responsibilities to fellow human beings. I smell burnout and/or campassion fatigue at work in this piece.

  • Kelly

    While I agree that 870 lbs is clearly unexcusable, I don’t think you can compare spelunking and obesity. Many Americans lack access to affordable, healthy food and eat dangerously because socioeconomic circumstances force them to. This is very different than optional risks like mountaineering or even alcholism.

    An interesting infographic on “food deserts:” http://www.good.is/post/food-deserts-an-interactive-map-of-the-places-in-america-farthest-from-a-supermarket/

    • ElleCB

      Agreed that you can’t compare spelunking and obesity, but I don’t think you can attribute socioeconomic factors to someone being that morbidly obese.

      Obviously I believe the healthcare realm should have accomodations for the overweight/obese, but you have to draw a line somewhere.

      I feel similarly to requiring hospitals to provide interpreter services for every dialect under the sun, and expect the hospital to eat the cost.

      • anonymous

        Good point on the interpreters.

      • Justin

        Eat the cost? No, they should bill for it.

        • http://www.practitionersolutions.com Niamh

          Love the pun!

  • Outrider

    >>are we then going to require that all hospitals purchase CT scanners and MRI scanners to accommodate patients of all weights – if those scanners even exist?>>

    These scanners don’t exist, but I wish they did. Most of my patients weigh at least 850 lbs. We can currently scan distal limbs and heads, but nothing else. Of course, I am an equine veterinarian. :-)

    Yikes.

    • http://prudencemd.com Prudence

      Honestly, I haven’t seen anyone weighing 850 lbs. I’m obese myself, but 850 lbs…that’s huge. I’m not sure about the U.S. population, but in here, an 850-lb individual is definitely an outlier, and I doubt if there’d be an institution here capable of handling such patient. I don’t believe that health institutions should be required to accommodate all these kind of patients, especially if it wouldn’t be cost-effective, business-wise. However, it will definitely help if hospitals would have the necessary equipment to be able to handle such patients. It would be deeply appreciated, from the point of view of these patients. However, I cannot imagine those kind of modifications being implemented here in a third-world country.

      • Outrider

        As I said already, I’d be delighted if scanners capable of fully accomodating my half-ton patients (which are horses, NOT humans) happened to exist. They don’t, and I doubt we’ll see them anytime soon. It is my understanding that this is a technological limitation, though I’m not an engineer or radiologist.

        Much of what equine veterinarians can do with horses is limited by the size of our patients, but everyone who works in my field appreciates these limitations. Not so in human medicine, thus this discussion.

        • http://www.practitionersolutions.com Niamh

          If a horse could speak what would he say?

          • Outrider

            I prefer patients that can’t speak. It’s restful, and I find them more interesting than most humans.

            Part of the challenge of being an equine veterinarian is in working with patients who easily outweigh me but are still willing to cooperate. Most of my patients are athletes, which is not the case in small animal medicine… or human medicine.

  • https://www.thejourneytomd.com Jeremiah

    There is a fundamental flaw comparing the the morbidly obese to higher risk activities. Which would the active consideration of the risk. Ask anyone who jumps out of planes for fun. They proactively engage in risk mitigation. Where as the morbidly obese do not.

    I can speak with authority on this because by definition I am morbidly obese. However I am in the minority, that realize that I stay big because I eat to much and do to little. A life time of bad choices doesn’t evaporate overnight. So I try to be as active as I can be and understand that I will always be hungry. That food can be as much a drug as anything else.

    My opinion is if an individual has made decades of bad choices that has put them in line for an early death then they are experiencing the effects of those choices. Yes we should try to save them, but spending billions to accommodate the slowly suicidal does no one any favors.

  • http://msrenegade.com Marie

    Dear me, I don’t know quite where to start.

    Ok, how about with some word substitution. How about we substitute the words “morbidly obese” with the words “HUMAN BEING”!! Or maybe “the disabled”? Because human beings and the disabled are so inconveniently imperfect, they should be lumped in with those undisciplined, slobbering morbidly obese freaks. Why should the rest of us, the Perfect Ones, have to go to any lengths to accommodate them? Everyone knows that someone who is morbidly obese deserves to die. After all, they did it to themselves. It doesn’t matter if they developed an eating disorder because they were sexually abused or they have a co-morbidity that keeps them from getting any exercise. They are disgusting parasites.

    “What should be a rational method of dealing with morbidly obese patients?” Hmmm. That is a good question. I suppose an answer like “With dignity and compassion” never occurred to you? Right, me either. Just because we have the technology and awareness of the needs of the morbidly obese, why should we use them? They have nothing to offer society, after all, no value, so investing in equipment that might accommodate them, help them heal and perhaps develop a healthier lifestyle is clearly not worth it.

    Thank you for opening our eyes! I can’t wait to see who is next on the Unworthy of Accommodation List.

    • Jenny

      Morbidly Obese is just scientific terms used to describe a person’s physical state. This article in no way stated that people who are Morbidly Obese are “disgusting parasites” or that a morbidly obese person “deserves to die.” All the article is stating is that there has to be some level of personal accountability for the decisions about our health. Yes, certain parts of the argument are flawed (like paralleling extreme overeating and inactivity to the risks adrenaline junkies take). No one is suggesting that morbidly obese patients be treated with anything less than dignity and respect. Still, patients who are morbidly obese need to understand that there are consequences to their decisions (such as higher health care bills to offset the price of more expensive clinical devices). No one is unworthy of accommodation, but this isn’t a perfect world and we don’t have a bevy of clinical resources at our disposal. People die everyday due to lack of available medical resources and it is tragic, but morbidly obese patients currently do not have the same available resources as those patients with lower body masses.

      Unfortunately I think you took this article at face value and instead of delving deeper into the issue and sparking a truly meaningful debate on how to help individuals who have unhealthy body masses, you fashioned a one-dimensional and defensive argument.

      The real problem with the majority of obesity cases in this country is the lack of access to proper food choices, and nutritional education, and healthy and affordable food options. And the unfortunate truth is that it takes hard work to stay healthy and many people prefer to be lazy and take the easy road. Until healthy and affordable food options are available, and people commit themselves to a healthy lifestyle, the obesity problem will never subside.

  • http://ironcut.blogspot.com Arkady

    Do you want a ‘reality check’? How about the reality check that Americans nowadays are bigger than ever. It’s a fact! There are too many things causing obesity. 1. inactivity, 2. junk food, 3. stress, etc. The causal factors do not seem to be going away anywhere. I don’t recall seeing any McDonalds closing in the past 15 years that I’ve been in this country, nor have I witnessed any less stress in people. People drive in record numbers rather than walk, more kids watch TV while eating crappy TV dinners, play video games, etc.

    Instead of thinking ways of saving money by ignoring our morbidly obese fellow human beings and denying them medical treatment, why don’t we save money by investing in preventative measures?

    Do you not treat an HIV patient because he/she didn’t take responsibility for his/her own actions and contracted the virus?
    Do you not treat an illegal immigrant child because she’s here illegally?

    Point being, obesity is part of current way of life. If you can invest in a technology to save a fellow human being’s life, do it… regardless of weight.

    “I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.”

    • Stalwart Hospitalist

      Thank you for the “special obligations” reminder; it is important to keep that in mind.

      It is also important to recognize that “special” is not equivalent to “unlimited”.

      I would be interested in hearing more details about “preventative measures” in which we can invest on behalf of other people. Many such measures, including public education, etc., have thus far failed to have much of an impact.

      • http://msrenegade.com Marie

        “It is also important to recognize that “special” is not equivalent to “unlimited”.”

        Ah, but it does mean unlimited. Note the word ‘all’.

        • Vox Rusticus

          I don’t think “all” is meant to imply “unlimited” as in meaning without limit to expenditure or use of resources. “All” is intended to mean without exclusion of particular persons or groups of persons.

          • http://msrenegade.com Marie

            Without exclusion of particular persons or groups of persons such as… hmm… I don’t know, maybe the obese?

            Since Hippocrates is no longer around to clarify whether he meant ‘all’ as in ALL sick and needy human beings or ‘all’ as in all that do not cost too much money, I’m going to stick with my interpretation, the former.

  • Kristin

    Some commenters make the good point that it’s hard to know where to draw the line. With liver failure patients, the issue isn’t that it’s morally wrong to keep drinking and that therefore we have no obligation to provide care–it’s that if they got a liver transplant, it would fail again. There’s a logical, practical consideration at stake. What’s the analogous situation with people who are morbidly obese? (And yes, in APA style, just as we started referring to “subjects” as “participants,” we now say “people with autism,” rather than “autistics.” Because words matter.) I’m not saying that there isn’t one, just that I don’t know it, not having a medical background.

    It’s not as if we refuse alcoholics all treatment. We still ferry them to and often from the hospital, give them benzos to treat the DTs, expect nurses and nurse aids to clean up after them–if it were a moral issue (which is what all prescriptive behavioral issues come down to, whether for good or ill), surely we would do none of these things.

    So, since we aren’t denying acoholics this level of care, why should we deny bariatric patients this level of care? What justifies having a drunk in an ambulance, but not a person with morbid obesity? What differs between the two cases that justifies a different response? If it’s simply the outlay on alterations, I’m not sure that’s morally or logically supportable. Twelve grand is chump change in healthcare. (Ask any CEO of a privately-owned hospital.) And most cities would need at most a couple of retrofits.

    (On a personal note, I’m queer. The position “Why should we spend all this money treating AIDs patients? They chose to have gay sex!” was quite popular for a long time, and still is in certain circles of ignorant people. I imagine you can extrapolate my relevant opinions from there.)

    So if you want to attack accomodations for people who are morbidly obese, don’t attack it on the grounds that we have no moral obligation to provide healthcare. Attack it on the grounds that the healthcare provided won’t work, whatever that means in this context. The medical system already has established precendent with respect to this type of situation–explain why that precedent either applies and supports your position, or doesn’t apply and should be disregarded. Don’t apply the precedent incorrectly. It makes logicians wince.

    • Bobbo

      Agreed.

      That being said, see this from a hospital CEOs perspective. That alcoholic pays just as much as any other patient (assuming insured) each time they come to the hospital. The morbidly obese patient may pay the same amount to the hospital, but costs the hospital far more in that they have to buy all this specialized equipment to deal with said patients. Should the hospital be required to pay for all the tools that would be used by only morbidly obese patients?

      I think that there should be facilities and modifications made to handle the needs of the morbidly obese. And i also think that morbidly obese should have to pay for those extra facilities through significantly higher insurance premiums or co-pays or what not.

      • http://prudencemd.com Prudence

        good point.

      • http://msrenegade.com Marie

        So we should make people pay extra for their obesity? Should the person who is obese because of congenital kidney disease and steroid treatment pay extra? What about the person with multiple sclerosis who can no longer exercise and whose meds cause weight gain? Or the woman who was raped and has developed an eating disorder?

        This sort of perspective is a throwback to the 19th century and differentiating between deserving poor and undeserving poor. It is shocking that health care providers have so little empathy and compassion.

        • Jenny

          Yes, people should pay more if their healthcare costs are more. That’s like saying all patients who are seen by a doctor or hospital should pay the same price for everything regardless of what or how many procedures were done, drugs given, services rendered, etc. It’s just the way things are that a heart transplant costs more than a checkup. My father had to have open heart surgery due to a genetic condition which weakened the lining of his aorta. Do you the hospital “discounted” his bill because his condition was not a direct consequence of his decision making? Absolutely not. This may sound harsh, but you can’t make monetary decisions on a case by case basis. That would create a truly biased and unfair medical system.

          The real focus should be on lowering overall healthcare costs for everyone. Preventative medicine is key to this issue.

        • Jenny

          Also, to be clear, it is extremely MS rarely causes the morbid obesity this case is discussing. The general cause of increased weight gain with MS is the use of the drug Elavil (which has alternatives and is generally not used due to the weight gain side effect). The most poignant part of the relationship between MS and obesity is that obesity can delay an MS diagnosis due to the complication that side effects of being extremely overweight can mask the symptoms of MS.

          • http://msrenegade.com Marie

            I am not entirely certain that I understand your argument in your first comment. But I can assure you that people with MS can gain significant amounts of weight, maybe not up to the 800 pound range, but still meeting the definition for morbid obesity. I know that because it’s happened to me. And Elavil had nothing to do with it.

            Between steroids and neurontin and no longer being able to walk every day, I rapidly gained weight, even though I was keeping my calories between 1500 and 2000 daily. I started swimming and that was helping. Until I fell and fractured my shoulder. Arm has never healed, no more swimming, weight has poured on.

            To look at me you would think that all I do is eat, not that I am, in fact, a light eater. But the same genes that kept my ancestors alive during the potato famine in Ireland in the 19th century are wreaking havoc with the immobilized me of today. I do not need specialized bariatric equipment (yet), but if I did, should I be held responsible for things I didn’t choose?

  • http://www.1107media.com Brad

    Nice article and a very valid question. Although not politically correct enough for some, questions like this need to be asked when dealing with those that engage in unhealthy behavior over an extended period of time. I say extended period of time as no one hits 800lbs overnight or loses a liver after a few beers.

    This issue is not one of valuing one human being over another, as one reader commented. It is one of personal, individual responsibility, regardless of abuses of the past. Any counselor worth their salt will tell you that overeating is not a good way to deal with a trial or problem from the past, just as drugs and alcohol are poor choices.

    Eating your way to 400, 800lbs and beyond is a choice. Eating high-calorie, high-fat foods vs healthy, low-fat, nutrient rich foods is a choice. At some point, we must all take responsibility for the choices we have made – good, bad or ugly.

    Thanks again for being brave enough to ask this difficult question. I for one believe it should be debated on a much larger stage.

  • http://paynehertz.blogspot.com Payne Hertz

    Does the author of this piece believe that people can reach a weight of 850 lbs without some kind of physiological disorder? If so, what keeps people who are 20, 30 or 50 lbs overweight from becoming 100, 200 or 500 lbs overweight? Do people allow themselves to gain a certain amount of weight, after which they then exercise the necessary self-discipline to keep from gaining more? That seems highly unlikely.

    The “Set Point Theory” states that the body is naturally inclined to maintain its weight at a particular level, and regardless of eating too much or too little above or beyond this point body weight will tend to balance around this level. While this theory remains unproven it certainly makes sense in light of the available evidence that even overweight people tend to remain in a particular weight zone over time, and this individual may simply have a far higher set-point due to abnormal metabolic factors.

    http://straighthealth.com/pages/dietitian/set-point-theory.html

    In either case I see no reason for the lack of compassion or panic over the trivial amount of money needed to retrofit an ambulance to accommodate this guy. $12,000 is chump change in a system that costs $2.3 trillion a year. Do you have any idea what a trip in an ambulance costs? They’ll make that money back in a day.

    I don’t regard a society that would allow people to suffer or die simply because they failed to maintain a state of perfection in their lives as being civilized. Do you?

    • http://www.thejourneytomd.com Jeremiah

      Do you have a reference that calls out what studies in what publications? It makes sense, but I am curious.

    • Stalwart Hospitalist

      There is no such thing as “chump change” when the system in unaffordable and destined for financial failure.

      • http://paynehertz.blogspot.com Payne Hertz

        $12,000 is not even one unnecessary back surgery’s worth of revenue for the average hospital. Seems there are a lot of more productive areas where the fat can be trimmed, pun intended. There as much chance of such a trivial amount of money breaking the system as an eyedropper inducing a tsunami.

  • solo fp

    If we don’t accommdate the obese patients, I am sure the lawyers will work a deal where it is discrimination. Already 20% of my hospital beds are special over 500 pound models. Sometimes it is not the weight of the person, as I have had 350 patients to wide or too deep to fit in MRI/CT machines that are rated at 350 pounds. It is very hard to get peripheral lines on the morbidly obese and very difficult to do physical exams on the morbidly obese.

  • Vox Rusticus

    People cannot reach 850 lbs without help from other people. At that weight, one is not ambulatory and thus not mobile or employable in any understandable sense. Someone has to get food and provide it to a person that size, and provide it to them often enough to be able to maintain that kind of weight. Getting that heavy is deliberate and corporate, in the sense one needs organization and another person able-bodied enough to bring the super-morbid obese person a food supply. These people are human beings, regrettably ones who have enlisted others in a self-destructive project of becoming four times normal adult weight.

    Leaning on set point theories is still an abdication of responsibility, as if one has no responsibility beyond one’s own appetite to gauge how much is appropriate to eat and when to stop, and whether to eat meals that are limited or eat constantly and indiscriminately–like a feedlot animal–as these persons evidently do. Likewise, saying “access” to healthy foods is denied to the poor is a condescending denial of their responsibility. Access is not denied when people choose to pay to drink highly-sugared soft drinks as opposed to water when they are thirsty, or to buy a bag of chips versus a banana for a snack. Poor does not equal stupid, and the low-income are just as capable of laziness as anyone else.

    As far as having a moral obligation to provide heavy-lift hoists and super-duty ultrawide stretchers to move grotesquely obese people, I don’t think any community ought to bankrupt itself to pay for those things. If some benighted private charity wants to make it their cause, have at it.

    • Cynic

      Well said. Very, very well said.

    • http://paynehertz.blogspot.com Payne Hertz

      The endless and mindless repetition of the “personal responsibility” mantra is nothing but corporate PR propaganda designed to absolve the food industry from its responsibility for the obesity epidemic. For the last few decades, they have spiked the food supply in America and elsewhere with an addictive substance that creates insulin resistance and consequent obesity and diabetes, as well as promotes overeating. This is why they put sugar in everything: because it makes you eat more.

      Many Americans have had their metabolism effectively wrecked for life as a result of consuming processed foods loaded with sugar, often starting as children with school lunches consisting largely of white bread, sugary drinks and “healthy” foods like fruit juices, which are loaded with fructose. Even now, people don’t understand the dangers because the dangers still are not being adequately explained to them.

      The medical profession has played a role in this, both by promoting diets based on the a-scientific food pyramid and demonizing diets which minimize refined carbohydrates as being “fads.” Additionally, medical societies like the American Heart Association have promoted breakfast cereals laden with sugar and refined carbohydrates as “healthy” and allowed them to carry seals indicating their approval. Endless promotion of “personal responsibility” dogma makes the obesity epidemic out to be the result of nothing but an alleged collective lack of discipline in the American people and provides a smokescreen for the food industry and what ought to be considered its criminal activity.

      Addictions are notoriously hard to beat, with fewer than 5 percent of alcoholics or drug addicts being able to maintain sobriety for more than 5 years, and with abstinence being the approved method of dealing with addictions. Food can also be addictive, but unlike the alcoholic, the food addict can’t just quit, but has to moderate his intake of food, as well as cope with the human metabolic system which has evolved to cope with reduced food intake by lowering metabolism and increasing hunger.

      Dieters have to try and lose fat without losing muscle or depriving their bodies of necessary nutrients, which is a balance far harder to achieve than the simplistic and inane “eat less, move more” mantra would imply. Only a small minority of people who are prone to obesity can maintain an ideal weight over time, roughly the same 5 percent as can beat a drug addiction.

      Rather than puritanical, spiteful, and hateful judgmentalism, isn’t it better to acknowledge these realities and work on solutions that take them into account? Isn’t it better to refrain from judging people who are overweight until you understand fully the realities of their circumstances and the degree to which they may have failed in their weight loss attempts due to wrong effort rather than lack of effort? Is it morally wrong to accept that some people just don’t have the monumental strength of will and iron discipline to maintain weight loss, or find the costs too extreme to bear, and adjust our expectations accordingly rather than always looking to penalize and degrade people for everything that falls short of perfection?

      • Vox Rusticus

        Stuffing personal responsibility into your category of “corporate PR” discredits your entire train of argument, unless you really believe people are nothing but helpless puppets at the mercy of commercial advertising and addiction. Evidence that people can be responsible and thoughtful actors that can make decisions in the interest of their own better health is all around, just as much as there is evidence of people who do not make those choices. The fact that some fast food company buys advertising for their greaseburgers doesn’t mean people are powerless before that advertising. Of course it is designed to be appealing, of course it is designed to be convenient. A thoughtful person will see that and realize there are choices, even at the drive-in window. A lazy or indifferent person may also see that but just not care.

        • http://paynehertz.blogspot.com Payne Hertz

          Though advertising plays a major role, we are not talking about advertising here, but addiction, and the fact the food industry is allowed to spike the food supply with an addictive substance to get people to eat more. If you don’t recognize any level of corporate responsibility here, then it would appear you are interested more in looking down on the obese than finding solutions.

          Of course, “personal responsibility” plays a role in that no one can lose weight without exercising personal responsibility. No one can do this for you, and no one, least of all me, is suggesting that you not try or give up.

          But blaming the entire populace of the US for the inevitable effects of the food industry’s despicable practice of spiking the food supply with an addictive substance that wrecks metabolism and induces overeating in most mammalian species shows a commitment to ideology in the face of facts..

          We jail crack dealers that sell crack to kids for a reason. But food manufacturers are allowed to stealthily addict our kids with a a substance every bit as addictive as crack and in the long term, more destructive.

          Rather than recognize the incredible difficulty of overcoming an addiction you may not even know you have as well as maintain weight loss over time (as evidenced by the fact so few can do it) you prefer to stigmatize people with a health problem as lazy, indolent losers.

          This makes as much sense as condemning people for failing to maintain a level of marathon-runner athleticism. After all, anyone can do it, right? Even the disabled.

          How about we work to compel the food industry to stop poisoning our food with sugar? That would be an excellent starting point for a legitimate campaign against obesity based on reason, rather than moral panic and political ideology.

          • ark

            The “addictive substance” which the food industry spikes the food supply with is sugar, right?

            I agree that a lot of food, generally processed food, has a ton of extra sugar, oftentimes in the form of high fructose corn syrup. This is bad. But, how come I know this is bad and purposefully avoid processed foods, high fructose corn syrup, extra sugar, etc., yet others are not personally responsible for avoiding unhealthy food as well?

            Until the food industry holds my mouth open and shoves the twinkies in to get me addicted to sugar, I am responsible for my own nutritional choices and thus I am also responsible for the appropriate weight I maintain.

  • http://www.mdwrites.com MD

    Perhaps impose a tax on people who are obese? The taxes will then pay for all the modifications that need to be made for hospitals, ambulances, etc. This will also provide an incentive for the obese to lose weight.

    • Stalwart Hospitalist

      Arizona is attempting to do this with its Medicaid patients — $50 per person per year if said person exceeds a standard definition of obesity.

    • http://paynehertz.blogspot.com Payne Hertz

      How about a malpractice tax? Same principle, different target.

  • Disillusioned

    So we have two basic ideas here: 1- Don’t spend the $12k on the rare patient that has obesity. 2- Don’t spend the $12k on the patient (rare or not) who chose to do this to his/herself.

    1- Half of the blood tests, lab tests, and other diagnostic tools should also not be provided in hospitals because some diseases are so rare that they provide so little benefit to the society as a whole. Let’s pick and choose to see which tests give the most value back to society and the rest of the patients with rare diseases can go and crawl in a hole somewhere and die (I’m assuming you’d say “good riddance, just don’t die near me”). Hospitals need to look out for the profit because that’s why we all came into the healthcare industry – to line our own pockets and watch out for the bottomline.

    2- Forget diabetes patients, HIV patients, STD patients, abortions, lung cancer patients, many heart disease patients, atherosclerosis, etc etc. Because as we know, most of these patients wouldn’t be in their state if they weren’t: eating too much sugar, having too much sex, smoking too much, eating too much food, not exercising enough.

    Yeah, I really agree with you. We should only treat pediatric patients who have sore throats. Of course, even then its their parents’ fault for taking their children to daycare – so screw them too.

  • Muddy Waters

    Obesity is a sign of the gross amount of excess in our society today. Just 60-70 years ago, being overweight was extremely rare. Nowadays, fat people are accepted and defended by the bleeding heart liberals that believe personal responsibility is not a choice. But fear not, because the age of oil (and excess) will soon come to an end (around 2050-2060). At that point, morbidly obese citizens will be hard to find once again.

  • http://www.practitionersolutions.com Niamh

    We’re in the business of helping people. Making a choice to sit in judgment of them does not help us to do our jobs properly. We absolutely must have a set of solutions to providing medical care for people who are morbidly obese. Perhaps a specialist level of home care services, a mobile care unit, a regional hospital with all the equipment as you mentioned. The obesity problem will only go away when the food industry is held to new standards. Not so easy to blame the obese person for their obesity. I think it’s more complex than that & who am I to judge? It doesn’t make them better. I doubt that they would have made this choice if they could have avoided it.

    • http://www.hieran.com Robin Mayhall, APR

      Niamh – you are so right. I feel like you strike a middle ground here. I’m not a healthcare professional, but I do work in the healthcare industry, and I am also overweight. I think my BMI is currently borderline obese, as I’ve been working to lose weight for several months.

      And that is why I feel qualified to comment on what Niamh brings up. I promise you no overweight or obese person chooses to end up weighing 400, 500 or 850 pounds. The choices are made one at a time, in the moment. Believe me, I knew every time I drank a non-diet soda or ate a piece of pizza that I wasn’t “eating right.” And when I did make the choice to commit seriously to weight loss, I have found the journey very, very hard. I have to make the hard choice now every time — to eat the low-fat food option, which also means to forgo the tastier option, or to exercise even when I don’t feel up to it. It has been expensive, emotionally difficult and extremely time-consuming.

      Please don’t take any of this as complaining. I fully realize I’m having to undo some poor choices of my own making. But it IS more complex than that. I also have rheumatoid arthritis, multiple stress fractures in my feet and a troublesome hip replacement, all of which makes strenuous exercise difficult. These factors also make drive-thrus and convenience food so much easier. I also take steroid medication that inhibits weight loss.

      I guess I just feel like we’re not going to get anywhere by arguing about who is to blame for a person’s obesity. I do agree that investing in more “prevention” and education is a great idea, and I think that patients need to take on a great deal of personal responsibility. But I also appeal to policymakers and healthcare professionals to have compassion as well and to see each patient as an individual with a complex past behind the current figure you see.

      • jenny

        I absolutely commend you for realizing you have to change your lifestyle choices and make healthier decisions. That is extremely hard for many people. And I encourage you to stick with it as it will be worth it %1,000. I understand the physical limitations that come with physical stress and pain. I’ve dealt with knee and hip issues for some time now (complications from a torn ACL) and I also suffer from poly cystic ovarian syndrome. While I was in College, before I was diagnosed and the ailment was managed, I suffered from severe joint pain, tingling in my limbs, and extreme fatigue. I was too tired to do anything, let alone cook for myself so I always relied on takeout and the joint pain kept me from exercise. It took over a year for a diagnosis. After 6 months I had gained almost 30 pounds (I had always been thin. I was a competitive gymnast and a competitive soccer player all throughout high school). As a 21 year old who had always been an athlete who loved healthy food, I hated being overweight and unhealthy. So I became determined to lose the weight and gain my health back regardless of how tired I was or how much pain I was in.

        First I focused on nutrition and scoured the internet for healthy and easy meals to make. Just by changing my diet I began shedding pounds and gaining energy. My joints became less painful and I just felt so much better. It truly is amazing how much your diet can affect you. Once I had enough energy and my joints felt better I began to start light exercise. I even did water aerobics, which, as a former athlete, I felt like a total loser doing it. But I realized that I should be proud of it. I was making a concerted effort for my health. It helped and by the time I was finally diagnosed I felt almost 100% without any medication.

        Today I rarely ever eat something that is really bad for me, just because it makes me feel awful. I still have pizza, burgers, etc, but they are all healthy versions of those things. And made the right way they are amazingly delicious.

        http://www.skinnytaste.com/ and http://www.kalynskitchen.com/ are 2 incredible websites for healthy, delicious and easy to make recipes.

        Stick with it!! You can do it! And you’ll feel much better once you do!

  • Frank

    Is the patient’s notion about a “glandular problem” that relevant that you would stand in judgement of that opinion. Like others here I have a problem with your presumption that morbidly obese people made a calculated decision to become so.
    You are concerned about the road we are going down in accommodating this illness. I am concerned about the slippery slope that you are embarking on when you suggest a physician would decide not to treat a patient because of the physician’s opinion as to the patient’s lack of responsibility in bringing on the illness.
    I volunteer in the ER. I see obese patients before they become morbidly obese. These patients are regulars. They are screaming for TLC. The vast majority seem to me to be suffering some form of mental depression. I know – I am not a doc. We are not recognizing and treating this illness soon enough. That is why people are morbidly obese.
    I was encouraged by your more positive comments about a more organized communal approach to handling morbidly obese patients – except that you seem to be using it as weapon. If you want treatment then you are going to have to travel long distances. My region has 14 hospitals. A very few of them are equipped to do cardio-vascular surgery. So people have to travel. So what?

  • http://myheartsisters.org/2009/11/14/bring-this-on-yourself/ Carolyn Thomas

    I love it when this general topic resurfaces! It always reminds me of Dr. Søren Holm’s observations in the Journal of Medical Ethics, about the National Insitutute for Health and Clinical Excellence, or NICE, and its controversial dilemma at the time: whether health care resources should be invested in patients whose conditions were considered to be self-inflicted. But Dr. Holm argued:

    “Participating in a number of sports and leisure pursuits, even at amateur levels, increases your risk of sustaining significant ankle or knee ligament damage requiring surgical reconstruction. This is also true of alpine skiing, squash playing, soccer, and many other sports. So if NICE takes its own principle seriously, we should expect guidance to orthopaedic surgeons that they are only to reconstruct sports-induced ligament injuries if the patient promises NEVER to play that sport again.“

    Dr. Holm concluded that U.K. physicians could not ethically withhold expert treatment from unreformed smokers or obese people, unless they also discriminate against fitness freaks with bum knees.

    • Vox Rusticus

      High energy sports that carry risk of joint injury also offer benefits of exercise. What benefit does overeating to obesity offer (except to support a weight-loss industry and increased medical care utilization)?

      • ElleCB

        People with sports injuries don’t require the extraneous accomodations that the grossly obese do. It’s not just a special lift in the ambulance. It’s every piece of equipment that they come in contact with in the hospital. Every procedure becomes greatly complicated, requiring additional equipment and increasing the chance of negative outcome. So now you’re retrofitting the entire hospital and requiring the use of more physicians and staff to care for the patient, which of course equals higher costs. Costs that the hospital will surely never recoup. And don’t start on the “it’s chump change”. Maybe a private for-profit hospital can handle it, but the community not-for-profits simply don’t have the finances to do it anymore.

        • http://paynehertz.blogspot.com Payne Hertz

          Could you post your evidence for this assertion?

          Compare the cost of retrofitting an ambulance or a wide stretcher that can accommodate a large person with the cost of but one unnecessary back surgery. I’m not kidding.

          Then compare that to the cost of workers comp claims and injuries to people who have to move people of ANY size, and realize these devices are not just good for overweight people. but for everyone needing an ambulance. EMS workers can injure their backs moving a 120 lb woman. Hospitals have all kinds of ways to recoup expenses.

          • ElleCB

            Could you post your evidence on all the ways that hospitals have to recoup their expenses? I can speak from experience that community not-for-profit systems are struggling to stay afloat. Medicare/Medicaid reimbursements have historically been awful, and now with the economic downturn the payor mix has shifted.

            Regarding the back surgery/obesity comparison; you’re simply looking at the cost of retrofitting an ambulance and stretcher. You also have to look at the multitude of diagnostic equipment that has to be modified, as well as physician/staff costs to care for an obese patient. Just placing a central line takes more time, more people, more supplies.

          • ElleCB

            Regarding workers comp and injuries from moving patients- I’m all for any assistance with moving patients regardless of location, but to my knowledge there is no device (for any weight limit) that prevents the use of EMS workers or nurses from lifting at some point. You still have to get the patient to the lift.

  • Carolyn

    This piece is deeply inhumane. Most people would be unable to get to a weight of 850 lbs. Someone who can even do this must be physiologically unusual and probably should be considered to have some kind of disorder. Maybe they have a leptin deficiency or something but in any case people at that kind of weight are very very few in number. Suppose you get someone in your hospital who weighs, say, 450 lbs. Should you not treat them with digniity and compassion? Suppose that person actually used to weigh 500 bls and has lost 50 lbs. Now what? is that person now okay to treat? The definiition of obesity would include plenty of people who weigh 200 lbs. WHat about them? They shouldn’t get treated either? THe definition of overweight can go down to 140 lbs or below. Maybe they shoudn’t get treatment either? This is a slippery slope.

    • Vox Rusticus

      What about suggesting that the morbidly obese have some responsibility for both their condition and their treatment–namely compliance with proper diet and exercise–is so “inhumane?” You do a disservice to this discussion by tarring those who would hold the patient responsible for compliance as “inhumane,” and you indulge yourself in argument ad hominem. Illness doesn’t automatically mean an excuse from responsibility.

  • ArkyDoc

    People who weigh over 500 pounds are often experiencing some mental health issues as well. I have taken care of a number of them in the hospital over the past few years, and at a certain point, most (if not all) are on disability. And, after a certain age, almost none of them can walk to the bathroom, clean themselves appropriately, etc. As Vox Rusticus pointed out, they certainly can’t drive to the store, buy their own food, cook it, clean up the kitchen. Their family members directly contribute to the problem. We have had several patients who reportedly “could not lose weight” in the hospital for several weeks (because no nursing facilities had the resources to care for them). All of them lost a very significant amount of weight on our standard hospital diet – while laying in bed because they were unable to walk. At weights over 500 pounds, these patients can’t walk due to knee and back pain; they can’t breathe due to the weight of their chest wall; nearly all have sleep apnea. There is a multitude of pathology related to their body weight. These people are not going to live to get old. I would be in favor of regional hospitals with integrated treatment teams for their physical health, mental health, rehab, etc. I have a great deal of compassion for these patients, but they truly are very difficult to care for.

  • greg zurbay

    This is a valuable discussion to have, but I think it lacks a certain level of complexity. #1. Everything “costs”. If you drink too much the expected result is of some negative health outcome. If you wish to take this path, should you not have to invest more to cover societal costs? If you are engaging in reasonable exercise to maintain health – and remain healthy should you not benefit from part of the cost savings to society? Should anyone be expected to contribute more for reason of a negative health result when the cause is traceable to the actions of someone else?

    We all are addictive machines. The differences appear in what and how much. I can be addicted to fruits and steak but still survive. Should I become addicted to lard, wine, butter, cigarettes, my health status will likely suffer. If I am addicted to fast motorcycles I should understand the potential of a small accident resulting in serious injury or worse. Still in all I would like to be able to pay an additional license fee to enable me to drive 30 MPH faster than the speed limit legally and accept the greater risk involved. You see I never drink when driving.

    We institute fines that are severe (loss of license) when someone speeds over 100MPH – this without any injury to anyone. Contrast that with the person at 500 – 600 – 800 lbs. They are not sanctioned, but have wreaked damage of substantial proportion.

    We have slowly changed our environment, and seem to ignore the many negative results. Cut out nature and no one values it anymore. Exercise in nature is now regarded as uninteresting and a hassle. Work is lacking in exercise benefit and often chock full of constant stress. The idea of students taking a study break and exercising outdoors is looked upon as being unproductive in gaining that competitive edge in the job market. Health is something that is ignored, hoped for, and “repaired” when it goes to shit.

    I think the family member smuggling twinkies to the bedridden 800 pounder should go to jail. The parent smoking around the kids should face sanctions. This isn’t rocket science, – we all know the results of this empty headed behavior. This is not benign behavior that leads to a bad outcome – this is the pistol with 1 bullet and you’re playing Russian Roulette – it’s only the timeline that is in debate.

    I don’t believe anyone should be without health care, but the republican party doesn’t want to pay any taxes, so the fact is many folks will be going without. It would be to everyone’s benefit to try to maintain good health. Your life could depend on it.

    I would hope the far right would promote healthy eating and exercise habits, but that might put a cramp in business profits, so – good luck.

  • Denise

    “Should people who eat themselves to death be treated any differently?”
    I say no they should not be treated differently. I work daily with obese patients and I can tell you that alot of these individuals are not in touch with reality when it comes to what has caused their obesity. Food can be an addiction like alcohol or drugs. You are right on with this discussion and I hope you continue to keep it real.

  • aek

    This post exhibits a stunning ignorance of medical ethics, biochemistry and the known science of obesity. Instead of trying to refute them w/ cites/evidence, which is impossible in a single comment, here are a few very readable science/research-based blogs which provide foundational and advanced concepts and clinical practice around obesity:

    The Whole Health Source (Stephen Guyenet, PhD, research neurobiochemist’s blog about obesity) http://wholehealthsource.blogspot.com/

    The Hastings Center Report (medical ethics) http://www.thehastingscenter.org/Search/Results.aspx?searchtext=obesity

    Dr Sharma’s Obesity Notes (Arya Sharma, MD, Canadian bariatric medicine clinician, researcher and policy expert) http://www.drsharma.ca/

    The Pump Handle (public health experts) http://www.google.com/cse?cx=017254414699180528062%3Auyrcvn__yd0&q=obesity+site%3Ahttp%3A%2F%2Fscienceblogs.com%2Fthepumphandle%2F&sa=Search

  • http://www.epmonthly.com/whitecoat WhiteCoat

    Wow. Gone for a couple days and my words have been twisted to make it appear as if this post was a call to crucify anyone with a BMI more than 25.

    First, those of you who created the strawman argument that I have some distaste for obese people, or that I don’t consider obese people “human beings,” or that I am “inhumane” for raising the issue need to stop sensationalizing and re-read the post.

    This article makes two points:
    First, how should we as a society allocate finite resources? Expenses aren’t limited to $12,000 for a hydraulic lift. Maintenance for the lift, larger stretchers, additional supplies such a blood pressure cuffs also must be factored into the costs. Should tens of thousands of EMS services across the US all be required to purchase and maintain all this extra equipment? Is everyone OK with subsidizing these extra expenses through higher property taxes and higher charges for already expensive EMS services? If ambulance services cannot afford these costs, what should they do?
    The issues has nothing to do with whether or not we should treat obese patients as “humans” or whether or not obese patients should be treated with “dignity and compassion.” Of course they should. The issue is how we should care for obese patients when necessary equipment to manage their medical needs is not available.

    Second, many commenters seemed to believe that obesity is beyond the control of a patient. I disagree.
    A low socioeconomic status forces people to eat fast food? That idea is offensive. What about a person’s socioeconomic status prevents that person from purchasing fruit and vegetables?
    Obesity is a psychiatric issue? Perhaps. Where are we going to find the services to treat them (remember that many states are cutting psychiatric services because they’re too expensive) and what are we going to do if obese patients refuse to obtain the services?
    Just yesterday, there was an article published about a 585 pound patient who lost 370 pounds by changing his diet and exercising. Obese patients can lose weight if they the will and encouragement to do so. I agree with Greg above that family members who “smuggle Twinkies” to bedridden morbidly obese patients should be ashamed of themselves.

    A few other thoughts come to mind when reading the comments.

    I have a problem with those who think that $12,000 is “chump change.” If $12,000 is such a miniscule amount, then why are medical services throughout the US drying up? The number of emergency departments in the US has decreased by 30% in the past year. Is that because they are making huge profits?
    It costs one ambulance company $12,000 for a lift plus thousands more in ancillary equipment and maintenance to transport morbidly obese patients. Talk to a few paramedics and ask them how “filthy rich” they and their employers are. I imagine that these additional costs would put many volunteer ambulance services out of business.
    Regarding transport, consider how EMS services will be able to transport morbidly obese patients up or down stairs. First responders have to be able to get the patient to the ambulance before they can use the hydraulic lift.

    While only tangentially pertinent to this discussion, I also wanted to address the misconception that several people had about hospital charges. Hospitals do charge a lot of money for the services that they provide. Does anyone know what percentage of those charges that the hospitals collect? A couple of months ago, I had surgery. When I got the bills for surgery, the insurance company reduced payment for the hospital’s charges by 66% to 85%. Charges for lab testing were reduced by more than 90%. Despite the high prices charged, many hospitals are having a difficult time staying solvent because they collect a small percentage of those charges.

    Finally, several people mentioned a “slippery slope” and asked where we should draw the line. That is a good point for debate. They also wondered whether “discrimination” against obese patients could allow doctors not to treat obese patients. It is already happening. Should we condemn those doctors who choose not to treat obese patients because they want to mitigate their risk?

    • aek

      #1 See my comment above with educational and eminently readable resources.

      #2 Use your own argument on trauma patients. Over half of all trauma incidents are directly preventable, and more are secondarily preventable (via regulation, oversight and public health mechanisms – oh yeah – let’s figure in the cost savings those have in the accidents and injuries prevented). They demand incredibly high numbers and types of resources, intensity of service and costs. They are big $$ losers.

      There is no perfect person who has zero health risk. All behavior carries risk/benefit in relation to health. How about let’s shine the spotlight on you: are you working or driving while sleep deprived? How about your diet: eating mostly processed foods and gulping soda? Caffeine up the wazoozle to stay awake during night shifts? A lot of couch time to wind down? Chair time by the hour in front of a computer? Do you wear a helmet every time you ride a bike? Do you even ride a bike? (That’s pretty damn risky, too.)

      No one escapes the dart of self-imposed health risk.
      Lastly, if you delve into the prevention literature, you will find that a significant number of people who suffer from obesity defer or deny themselves any sort of care at all. They perceive humiliation, condemnation, dehumanization and demoralization at the hands of treaters.

      The lack of empathy and the tone of this piece is a stellar example of why people stay away until they are in dire straits – or dead.

      KevinMD should not give such uninformed and unethical tirades high visibility without at least giving an obesity expert equal space to refute it and to educate.

      Disappointing, but oh so not surprising.

  • http://paynehertz.blogspot.com Payne Hertz

    Everyone involved in the debate should read this study. It covers many of the bases and dispels a lot of myths.

    The epidemiology of overweight and obesity: public health crisis or moral panic?

    http://ije.oxfordjournals.org/content/35/1/55.full

    The current scientific evidence should prompt health professionals and policy makers to consider whether it makes sense to treat body weight as a barometer of public health. It should also make us pause to consider how propagating the idea of an ‘obesity epidemic’ furthers the political and economic interests of certain groups, while doing immense damage to those whom it blames and stigmatizes.

  • http://msrenegade.com Marie

    I’m sorry if you feel your perspective was misinterpreted. However, after re-reading your essay several times I still get a strong undercurrent of hostility and blame. You say “perhaps” there is a psychiatric component. Perhaps?!? Who in their right mind would allow themselves to reach a weight of over 800 pounds?! Of course there is a psychiatric component. If services are being cut, residents in every state are obligated to contact their legislators. That is an area that affects all of us. If people suffering with obesity won’t take advantage of those services, then that is their prerogative and we are still obligated to give them the best care possible.

    If we have the technology and equipment to help these poor people, it is a good thing. No one is forcing anyone. “Should we condemn those doctors who choose not to treat obese patients because they want to mitigate their risk?” If that is their reason, absolutely.

    I also have to comment on your statement “A low socioeconomic status forces people to eat fast food? That idea is offensive. What about a person’s socioeconomic status prevents that person from purchasing fruit and vegetables?” With all due respect, you need some consciousness raising about living at the poverty level. I can tell you what prevents someone from purchasing fruit and vegetables. They are expensive and unavailable to people who have no close supermarket and no car.

    I live two blocks from Asbury Park, New Jersey, a city with a large population at or below the poverty line. There is only one crappy supermarket in the town, in the far north east section, a long, tough walk with groceries. But there are many fast food joints throughout. So that is where people go. Nothing offensive about the idea at all, it is a reality. Well, nothing offensive, that is, except that people in the United States are living like this without access to good, nutritious food. I invite you to visit Asbury Park, the soup kitchen at our church and the Last Resort Pantry we run and then tell me nothing about a person’s socioeconomic status prevents them from purchasing fruits and vegetables. I have attached the website. Perhaps you would like to make a donation?

    http://www.trinitynj.com/3food.html

  • http://paynehertz.blogspot.com Payne Hertz

    I have to say that the compassion for “grossly,” “grotesquely,” “super-morbid,” “personal-responsibility”-shucking and “morbidly” obese people expressed here is quite touching. We will happily let you die and let some EMS worker injure his back rather than pay $12,000 to retrofit an ambulance, but rest assured, it’s for your own good.

    How did we ever come up with a term as “grossly” and “grotesquely” offensive as “morbidly obese” anyway? Do we talk about the “morbidly cancerous” or, for that matter, the “morbidly anorexic?” As it’s commonly used, the term “morbidly,” with it’s association with death and gloominess, is hardly a term of endearment. From Dictionary.com:

    mor·bid
    –adjective

    1. suggesting an unhealthy mental state or attitude; unwholesomely gloomy, sensitive, extreme, etc.: a morbid interest in death.
    2. affected by, caused by, causing, or characteristic of disease.
    3. pertaining to diseased parts: morbid anatomy.

    The implication of this term is that overweight people are diseased both mentally and physically. It is a term of opprobrium and shame, and speaks of a system that pollutes medical care with character assassination. I imagine the same guy who came up with this term also coined “exquisitely sensitive” for chronic pain patients.

    • anon MD

      The official definition of “morbidly obese” is 100 pounds or more above ideal body weight. (Just “obese” is 25% above ideal body weight.) Why one is an absolute number and the other a percentage I have no idea. We can argue over whether this term should be changed to be more sensitive, but this is the current definition. When commenters used “grossly”, “grotesquely”, or “super-morbid”, they were not using official medical terms.

    • Vox Rusticus

      Adjectives, Payne, they’re what’s for dinner. Thank you for the suggestion for adopting a bland, non-judgmental newspeak. I’ll pass, thank you.This is a blog string, not a professional encounter, and responders here are allowed to come here gloves-off as it were, within Kevin’s rules. I can say to you and anyone else that I do not think myself beholden to anyone here to pretend I don’t think that super-morbidly obese people who eat themselves to non-prime integer multiples of normal body weights are significantly responsible for their situations. They may have mental illnesses, but obesity to the point of immobility requires significant resources and industry not only on the part of the patient but from those recruited to support the patient. Like the chronic alcoholic, the “victim” has to take the poison himself.

      The question of the OP is how far should a community have to go to accommodate people who eat themselves to the point they cannot be accommodated in vehicles and with stretchers that are already fairly heavy duty, but not enough say, to safely lift a 500 pound patient, without risk to the patient or the ambulance crew. Even if devices could be made (at some expense $12,000 in the example given) does that mean the public should have to make that kind of instrument commonly available, at the public’s expense? And if so, what is a reasonable accommodation? A crane to lift a 500 pound patient from a second story home? Or do we need equipment to lift larger people than that? It is a matter of degrees, since the providing of EMS personnel and ambulance equipment is not at issue–that is settled and done. But moving someone as large as described requires more resources than a hoist; it means calling out possibly an entire ready crew from a fire station or three ambulance crews for one patient.

      From the posts here, some feel that the right amount of equipment is whatever it takes and damn the expense. Here’s news: those days and that kind of thinking are done. The $30,000 or $50,000 you spend to upgrade an ambulance fleet and buy extra equipment is money that won’t be available for other public needs. Something else is not going to be available, and that isn’t trivial, even if you aren’t writing the check yourself.

      I will be the first to say that a morbidly obese person does not have a right to command the same resources as a person with just as immobilizing a condition whose situation is not so self-inflicted.

  • Bev D

    You call it “reality check” and I call it a judgmental approach. This is a dangerous road to follow because of what it says across in all areas. Should we stop doing medical research for HIV/AIDS because the majority of the cases might be lifestyle based? Of course not — stop playing God. Our society should work to the best of our ability to accommodate all persons and to expand our capability to do so.

    • ElleCB

      Read Vox Rusticus’ post above. Proper use of resources isn’t judgmental; this has become a zero sum game and someone has to choose where the resources go.

      I’m not sure if those screaming how inhumane this all is don’t actually work in healthcare or if you’re just that blind, but at some point you have to draw a line. Healthcare presents a plethora of ethical dilemmas, and just like we can’t let one patient deplete the regional supply of plasma, we also can’t let one group of patients deplete what resources we may have that could better serve the greater populus. Spending ridiculous amounts of money on retrofitting equipment for a minority just may cut the funding to other necessary programs.

      • http://msrenegade.com Marie

        There is a difference between one patient depleting the regional supply of plasma and telling someone ‘you are not going to get the care you need because you did this to yourself.’

        My main concerns on this issue are the undercurrents of contempt and the fact there is no ethical way to determine who truly is to ‘blame’ for their condition and who is a victim of genetics, illness and/or medication. And who makes that call?

        The obesity epidemic is a huge social, health and behavioral crisis, but I am hearing scorn and superiority in many of these comments rather than patience and empathy. The solutions offered in some cases are punitive, not curative. As a healthcare professional, my opinion is that until the day we live in an ideal world where everyone is happy and healthy, we are obligated to provide whatever is necessary to help people regain their health. Yes, even if it means we all have to share the cost. That is what we do in a civilized and ethical society.

        • ElleCB

          But the reality isn’t just sharing the cost, it’s which program gets money and which one doesn’t? I work for a rather large not-for-profit system but even we can’t fund every program. Other hospitals in the area have had to close their doors or significantly cut service lines. We’re fortunate that we’ve run barely enough margin to stay open and employed, but that leaves our ability for charity care and community benefit programs greatly reduced. And systems like ours all across the county are in the same shoes.

          So as I said before, this has become a zero sum game. We can’t fund them all. To fund one program means not funding another. There are very deserving and needed services that we just can’t provide because we have to prioritize by what helps the most people and makes the greatest impact.

          I absolutely don’t believe in treating the morbidly obese as inferior, or with any less respect than every person deserves. But it just isn’t possible to use what little funding there is to cater to such a limited population.

    • http://www.epmonthly.com/whitecoat WhiteCoat

      “Accommodate all persons and to expand our capability to do so.”

      Great. I think that the medical systems should have helicopters and crews available at any site that is more than a 30 minute trip to a hospital. That would “expand our capability” to accommodate those patients with true emergencies so that they could get care quicker.

      If that sounds silly, where do you draw the line between advocating for one type of transport and not another? Wouldn’t that be “playing God” with people that would otherwise die if they didn’t have faster medical care?

      Sorry, but your whole “playing God” argument is inflammatory and inappropriate. Perhaps medical care should just be withdrawn in this country. Medical technology has more than doubled the average life expectancy of human beings since ancient Greece and Rome (28 years then to 67 years now). Using your logic, if God wants someone to die, then we’re really “playing God” by prolonging that person’s life, aren’t we? Or are we really “playing God” because we don’t invest all our money in research so we can figure out how to make people live even longer?

      Advocating for the “best health care that someone else can pay for” will just lead us to a medical system that collapses in debt that much quicker than is already happening.

      Who will you accuse of “playing God” when the government can’t afford to provide basic medical care to its citizens in a timely fashion and many more people die due to lack of basic medical care? Trust me, we’re not too far away from that situation now.

  • Elizabeth

    I agree that patients need to take some responsibility for themselves, and having worked in a huge inner city hospital, I’ve seen the worst of patients who don’t or aren’t able to do this. What’s the end result, though? Do we refuse to care for a morbidly obese patient if he’s having chest pain or his blood sugar is sky high? The medical establishment speaks out of both sides of their mouth. You say that a patient needs to take responsbility for what they eat, but the schools, etc. remove snacks and tell students what they can and cannot eat. Restaurants are forced to include nutritional information for the food they provide…This is telling people what they can and cannot eat. Smoking……Bad, Bad, Bad for you. I agree. It’s been almost 25 years since I’ve smoked, but banning everyone from smoking everywhere…..is this the solution? No one likes to be forced into anything. Instead of taking away people’s choices, give them alot of good information. This might work better. and… White Coat, please remember, is the word ‘compassion’ in the Hippocratic oath?

    • http://www.epmonthly.com/whitecoat WhiteCoat

      You, like others, are creating strawman arguments and are sensationalizing. You turn an argument about allocation of resources into some diatribe about snacks in schools and banning smoking.

      First, in answer to your strawman question, no we don’t refuse to care for obese patients. We do the best to care for them with the equipment we have available — just like with any other patient. The issue is not “refusing care” the issue is “no equipment available.”
      If morbidly obese patients can’t be transported because there are no ambulance stretchers large enough to hold them or there are not enough paramedics available to lift them, how exactly is that “refusing care”?
      If a community hospital doesn’t have the resources to care for a trauma patient in a car accident, are the medical providers showing a lack of “compassion” because they transfer the patient?

      You recommend providing people with “good information”. Don’t you think that trying to have a rational discussion about this issue is “good information”?

  • Dorothy Green

    “Restaurants are forced to include nutritional information for the food they provide…This is telling people what they can and cannot eat”

    NO. It is not! Do you take issue with the Nutritional Facts on food packages? Information about what your putting into your mouth? Do you ever read them. Who is banning people from smoking? Prohibition doesn’t work with anything.

    Addiction to whatever – here we are talking about food – is both an individual responsibility – what each of us put in our mouths – and what is out there to choice from. Dr. Frank Parks from Harvard School of Public Health said this a few years ago in explaining that we cannot absolve individual responsibility in obesity.

    The American Eating Culture is the leading cause of health care costs and deaths in the US. It is no longer smoking. It is spreading around the globe. At this point, we are on a slippery slope of wiping out our economy by passive acceptance of the addictive substances that cause humans to overeat. These are sugar, fat and salt. Yes, of course we need glucose, essential fats and a bit of sodium and all that can be worked out. We all have the potential for addiction.

    The real issue is NOT that a person is addicted to sugar, fat and salt or tobacco, drugs. The issue is how much you and I as taxpayers are paying for the healthcare costs of these addictions.

    When politicians talk about raising taxes to pay for heatlhcare what taxes are they talking about? It is income taxes mostly and that really makes me mad as hell.

    I propose that income taxes be reduced, loopholes closed, subsidizies to unhealthy food stopped (think corn), a VAT is used for general consumption and tax upfront on the addictive subtances of processed sugar, processed vegetable oils, artificially (corn, soy – fed animal meat (which is most – cows are supposed to eat grass and chickens are supposed to eat slugs and grass). Of course, all the natural food (can’t deal with organic vs non here) would be RISK FREE.

    The tobacco model has worked quite well. The US is continuing to put messages on packages (seen any of the new ones? wow!) and even talk of more tax on cigarettes. Why aren’t we doing this with what causes the addiction in food? Not a soda tax on ounces but rather an across the board tax (call it RISK – reduction in sickness kitty) on all processed sugar in grams (following the Nutrition Facts) and provide a strong warning message that excess sugar increases the risk of diabetes type II, heart disease etc (I haven’t included potato chips here but you get the idea)

    It is the most logical thing to do. The revenue will be more than 100 billion/year at say $.003/gm of sugar. This is a lot of money that can be put to very good use in healthcare – education, vouchers for vegetables and fruits for the poor, healthcare tax credit for taxpayers etc. even jobs (there would be an exchange of jobs but probably a net increase).

    The person who weights 850 lbs, even 350 would have paid for the ambulance but a better scenario is that the money this person paid upfront for the RISK of overeating would 1) discourage this behavior 2) send a strong message 3) would be in the system to PREVENT this human tragedy from ever occurring.

  • Wendy

    As to the question to have a regional hospital specifically set up for bariatric patients, or residents, because they will be there for awhile…I say absolutely. There are hospitals that specialize in all kinds of traetments and health issues and have the equipment to do so.
    Most of the patients I see as an Ombudsman are actually residents in nursing homes; and on Medicaid. They have all kinds of health issues, mainly due to the obesity, that are ‘treated’ while they are a resident, and then when a health issue becomes too much for the home to take care of, they are taken to hospitals (in larger sized ambulances) for care, and then they return back to nursing home…eventually.
    The problem I have is that the residents I deal with are not being treated at all for thier obesity. They are allowed to eat whatever they want-they have food stockpiled in room and or brought to them by family and friends. Meanwhile they get heavier and heavier and it cost more and more to care for them.
    I am able to put my feelings aside on the whole Medicaid issue that I DO have while I am interacting w/ these residents….after all I AM a Resident Advocate, but I DO see a TON of waste going on here with monies not going to where they need to be , and it would be handled better if we looked at this whole issue of obesity different. It needs to be a long term treatment plan, and I think having Regional Resident Facilities that are able to deal w/ larger people and get them on the road to recovery, instead of just wharehousing them, is the way to go.

  • http://msrenegade.com Marie

    Dr. WhiteCoat, replies have been sensational because, the way it was written, this is a sensationalized topic. It hits many sore spots, both for people who struggle with their weight and for people who resent your implications.

    You may not have intended it, or maybe you did, but your written voice on this subject reeks of derision. And your premise is actually a bit silly when you think about it. Pointless, really. Of course we cannot outfit every medical facility with every piece of equipment for every eventuality. That is a ridiculous notion. And one that no one here is proposing. No one is even proposing it for bariatric patients. But the underlying, palpable contempt in your essay for people who are suffering with morbid obesity is disturbing and inflammatory. You can hide behind the claim that this is about economics but it really feels much more like a cheap shot at a vulnerable population.

    Your words, quite simply, are hurtful. But there are health care providers out there who are still idealistic and compassionate. That is why you have received so many defensive and strongly worded comments. People care. And, right or wrong, they care more about human beings than the bottom line.

    • Matthew Robinson

      I believe that there is a finite amount of resources in the medical field. These resources include time, money, and physical energy. I think that it is unreasonable and unachievable to ask medical professionals (physicians, nurses, therapists) to selflessly commit themselves (and the limited resources they work with) to all patients, without a care system based in reason and rationality.

      It is a fact that it takes more time and strength to turn a patient weighing 400 pounds than it does someone that weighs less than half of that. Therefore, the man/woman power required for the care of the 400 pound patient is greater. The other patients on the floor, who also are in need of appropriate care, receive less of these finite resources. Is that fair? Therefore, if it takes more time and energy, shouldn’t the obese patients pay more for their care? If I asked you to move two tons of rocks for $50, or 100 pounds for the same amount, which do you think is more reasonable, and which would you prefer to do? It’s easy for people to knock medical professionals for earning a good living, and easier to ask them to provide “equal care to all”. Realistically though, the budgets of hospitals could be exhausted in days if it weren’t for the judicious use of money and resources in the most appropriate way. It is not an easy decision to make, or a comfortable discussion to have, but I applaud people who risk being unpopular for the sake of the future, whether the topic is healthcare, finance, or law.Turning a blind eye to obesity because people are sensitive to the social implications of the term is a disservice to the medical world, and to society. 

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